Menopause is the permanent end of menstrual periods and thus of fertility.
During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the ovary (ovulation) about 2 weeks after the first day of a period. For this cycle to occur regularly, the ovaries must produce enough estrogen and progesterone (see Biology of the Female Reproductive System: Menstrual Cycle). Menopause occurs because as women age, the ovaries stop producing estrogen and progesterone. During the years before menopause, production of estrogen and progesterone begins to decrease, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and ovulation end permanently, and pregnancy is no longer possible. A woman's last period can be identified only later, after she has had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed since their last menstrual period.)
A distinctive transitional period called perimenopause occurs during the years before and the 1 year after the last menstrual period. How many years of perimenopause precede the last menstrual period varies greatly. During perimenopause, estrogen and progesterone levels fluctuate widely. These fluctuations are thought to cause the menopausal symptoms experienced by many women in their 40s.
In the United States, the average age for menopause is about 51. However, menopause may occur normally in women as young as 40. Menopause is considered premature when it occurs before age 40 (see Menstrual Disorders and Abnormal Vaginal Bleeding: Premature Menopause). Premature menopause is also called premature ovarian failure.
During perimenopause, symptoms may be nonexistent, mild, moderate, or severe. Symptoms may last from 6 months to about 10 years.
Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often, but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become regular again. In some women, periods occur regularly until menopause.
Hot flashes affect about three fourths of women and usually begin before periods stop. Most women have hot flashes for more than 1 year, and up to one half of women have them for more than 5 years. What causes hot flashes in unknown. They may be related to fluctuations in hormone levels and may be triggered by cigarette smoking, hot beverages, certain foods, alcohol, and possibly caffeine. During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing the skin, especially on the head and neck, to become red and warm (flushed). Women feel warm or hot, and perspiration may be profuse. Hot flashes are sometimes called hot flushes because of this warming effect. A hot flash lasts from 30 seconds to 5 minutes and may be followed by chills. Night sweats are hot flashes that occur at night.
Other symptoms that may occur around the time of menopause include mood changes, depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue. Many women experience these symptoms during perimenopause and assume that menopause is the cause. However, evidence supporting a connection between menopause and these symptoms is lacking. These symptoms are not directly related to the decreases in estrogen levels that occur with menopause. And many other factors (such as aging itself or a disorder) could explain the symptoms.
Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship between fatigue, irritability, loss of concentration, and mood changes seems less clear.
Many of the symptoms that occur during perimenopause, although disturbing, become less frequent and less intense after menopause. However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, increasing the risk of osteoporosis). These changes may worsen, unless measures to prevent them are taken.
In about three fourths of women, menopause is obvious. Thus, laboratory tests are usually not needed. If menopause begins several years before age 50 or if symptoms are not clear-cut, tests may be done to check for disorders that can disrupt menstrual periods. Rarely, if menopause or perimenopause needs to be confirmed, blood tests are done to measure levels of estrogen and follicle-stimulating hormone (which stimulates the ovaries to produce estrogen and progesterone).
Before any treatment is started, doctors ask women about their medical and family history and do a physical examination, including breast and pelvic examinations and measurement of blood pressure. Mammography is also done. Blood tests may be done, and bone density may be measured, particularly in women with risk factors for osteoporosis (see Osteoporosis). The information obtained helps doctors determine the woman's risk of developing certain disorders after menopause.
Understanding what happens during perimenopause can help women cope with the symptoms. Talking with other women who have gone through menopause or with their doctor may also help.
Noting which foods and beverages (such as coffee, tea, and spicy foods) seem to trigger hot flashes and not consuming them may help prevent this symptom. Not smoking and avoiding stress may help relieve hot flashes and improve sleep.
Wearing layers of clothing, which can be taken off when a woman feels hot and put on when she feels cold, can help her cope with hot flashes. Wearing clothing that breathes, such as cotton underwear and sleepwear, may enhance comfort.
Exercising regularly (particularly aerobic exercise) may help prevent or relieve hot flashes and improve sleep. Relaxation techniques, meditation, massage, and yoga may help prevent or relieve hot flashes and relieve depression, irritability, and fatigue. A technique called paced respiration, a type of slow, deep breathing exercise, may also help hot flashes. Weight-bearing exercise (such as walking, jogging, and weight lifting) and taking calcium and vitamin D supplements slow the loss of bone density. Regular exercise, particularly when combined with a diet lower in calories, fat, and cholesterol, also helps women lose weight, lower cholesterol levels, and reduce the risk of atherosclerosis, including coronary artery disease.
If vaginal dryness makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. Staying sexually active also helps by stimulating blood flow to the vagina and the surrounding tissues and by keeping tissues flexible. Kegel exercises may help with bladder control (see Pelvic Floor Disorders: Exercises). For these exercises, a woman tightens the pelvic muscles as if stopping urine flow.
Hormone therapy can relieve moderate to severe symptoms such as hot flashes, night sweats, and vaginal dryness. However, hormone therapy may increase the risk of developing certain serious disorders. Whether to take hormone therapy is a difficult decision that must be made by a woman and her doctor based on the woman's individual situation. For many women, risks outweigh benefits, so this therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, benefits may outweigh risks.
Hormone therapy can include estrogen and progestins, such as medroxyprogesterone acetate. The hormones used in hormone therapy are synthetic hormones, made in laboratories. They may or may not be identical to those made in the body, but the way they act in the body is very similar. Estradiol is the form of estrogen usually used. Progestins resemble progesterone, which is made by the body.
Women who have a uterus are usually given estrogen plus a progestin (combination hormone therapy) because taking estrogen alone increases the risk of cancer of the uterine lining (endometrial cancer). The progestin helps protect against this cancer. Women who no longer have a uterus may take estrogen alone.The benefits and risks depend on whether the hormones are taken alone or together.
Estrogen has several benefits:
Estrogen taken alone increases the risk of the following:
Combination hormone therapy reduces the risk of the following:
Combination hormone therapy increases the risk of the following:
Progestins have some benefits:
Progestins may increase the risk of the following:
Estrogen taken alone does not increase or decrease the risk of coronary artery disease. Dementia risk may be increased with estrogen-alone therapy. The effect of estrogen alone or a progestin alone on the risk of breast cancer and blood clots in the lungs is also not clear. Estrogen and progestins, especially at high doses, may have side effects, including nausea, breast tenderness, headache, fluid retention, and mood changes.
Estrogen and a progestin can be taken in several ways:
As tablets taken by mouth, estrogen and a progestin may be taken as two tablets or as a combination tablet. Commonly, estrogen and a progestin are taken every day. This schedule typically causes irregular vaginal bleeding for the first year or more of therapy. Alternatively, estrogen may be taken daily, with a progestin taken for 12 to 14 days each month. With this schedule, most women have monthly vaginal bleeding.
Using an estrogen cream is as effective as taking estrogen by mouth for preventing or relieving drying or thinning of the vagina. The cream may be applied to the vagina, or an estrogen tablet or a ring containing estrogen (similar to a diaphragm) may be inserted into the vagina. Such treatment helps prevent intercourse from being painful. Some of the estrogen cream is absorbed into the bloodstream, particularly as the vaginal lining becomes healthier. The amount of estrogen absorbed into the bloodstream from the vagina depends on the type and dose of estrogen used. The amount of estrogen absorbed with creams is much higher than that with vaginal tablets or rings. Theoretically, estrogen absorbed through the vagina can increase the risk of endometrial cancer. Therefore, if women who have a uterus use estrogen creams, they should also take a progestin. Occasionally, women who have breast cancer or who have risk factors for it are offered a vaginal tablet or ring, but only after they have been evaluated by an oncologist.
Doctors prescribe the lowest hormone dose that controls symptoms. If women have symptoms while taking a high dose, the hormone level in the blood is measured to determine whether the hormone is being absorbed.
Selective estrogen receptor modulators (SERMs):
These drugs function like estrogen in some parts of the body. The only SERM currently used to prevent bone loss related to menopause is raloxifene. Like estrogen, raloxifene helps prevent bone density from decreasing in postmenopausal women and increases the risk of developing blood clots (from 1 to 10 in 10,000 women). Raloxifene also prevents fractures of the bones in the spine (vertebrae). However, raloxifene may have effects opposite to those of estrogen in other parts of the body. It does not relieve menopausal symptoms. Hot flashes worsen mildly and temporarily in about 1 in 10 women. Also, raloxifene does not appear to increase the risk of endometrial cancer. It inhibits the growth of breast tissue and reduces the risk of breast cancer.
Several other types of drugs can help relieve some of the symptoms associated with menopause. Clonidine, which is used to treat high blood pressure, can reduce the intensity of hot flashes. It can be applied in a skin patch. Gabapentin, an antiseizure drug, may lessen the frequency of hot flashes. An antidepressant, such as fluoxetine, paroxetine, sertraline, or venlafaxine, may relieve hot flashes. Antidepressants may also help relieve depression, anxiety, and irritability (see Mood Disorders: Drug Therapy). A sleep aid can often relieve insomnia (see Sleep Disorders: Treatment).
Lipid-lowering drugs (see Cholesterol Disorders: Lipid-Lowering Drugs) may be taken to lower cholesterol levels, reducing the risk of atherosclerosis and coronary artery disease. Women with risk factors for osteoporosis can take bisphosphonates to reduce that risk (see Osteoporosis: Drugs). These drugs increase bone density and reduce the risk of some fractures.
Testosterone, the main male sex hormone, taken with estrogen is sometimes used to relieve some symptoms of menopause. This treatment is controversial because whether taking estrogen with testosterone is more effective than taking estrogen alone is unclear. Also, taking testosterone has risks and side effects, such as an increased risk of liver disorders and masculinizing effects.
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Some women take medicinal herbs and other supplements to relieve hot flashes, irritability, mood changes, and memory loss. Examples are black cohosh, DHEA (dehydroepiandrosterone), dong quai, evening primrose, ginseng, and St. John's wort. However, such remedies are not regulated as drugs are. That is, their manufacturers are not required to show that they are safe or effective, and what their ingredients are and how much of each ingredient a product contains are not standardized (see Medicinal Herbs and Nutraceuticals: Safety and Effectiveness). Also, none of these treatments has been shown to be effective, and some, such as black cohosh, vitamin E, and increased dietary soy protein, have been shown to be ineffective. Some (for example, kava) are harmful. Furthermore, some supplements can interact with other drugs and can worsen some disorders. Women who are considering taking such supplements are advised to discuss them with a doctor.
Last full review/revision June 2007 by Susan L. Hendrix, DO